Stomach

Introduction

The stomach is a hollow organ in the upper abdomen, under the ribs.

It's part of the digestive system. Food moves from the mouth through the esophagus to the stomach. In the stomach, the food becomes liquid. Muscles in the stomach wall push the liquid into the small intestine.

The wall of the stomach has five layers:

Inner layer or lining (mucosa): Juices made by glands in the inner layer help digest food. Most stomach cancers begin in this layer.

Submucosa: This is the support tissue for the inner layer.

Muscle layer: Muscles in this layer contract to mix and mash the food.

Subserosa: This is the support tissue for the outer layer.

Outer layer (serosa): The outer layer covers the stomach. It holds the stomach in place.

Cancer Cells

Cancer begins in cells, the building blocks that make up tissues. Tissues make up the stomach and other organs of the body.

Normal cells grow and divide to form new cells as the body needs them. When normal cells grow old or get damaged, they die, and new cells take their place.

Sometimes, this process goes wrong. New cells form when the body doesn't need them, and old or damaged cells don't die as they should. The buildup of extra cells often forms a mass of tissue called a growth, polyp, or tumor.

Tumors in the stomach can be benign (not cancer) or malignant (cancer). Benign tumors are not as harmful as malignant tumors:

Benign tumors:

are rarely a threat to life

can be removed and usually don't grow back

don't invade the tissues around them

don't spread to other parts of the body

Malignant tumors:

may be a threat to life

often can be removed but sometimes grow back

can invade and damage nearby organs and tissues

can spread to other parts of the body

Stomach cancer usually begins in cells in the inner layer of the stomach. Over time, the cancer may invade more deeply into the stomach wall. A stomach tumor can grow through the stomach's outer layer into nearby organs, such as the liver, pancreas, esophagus, or intestine.

Stomach cancer cells can spread by breaking away from the original tumor. They enter blood vessels or lymph vessels, which branch into all the tissues of the body. The cancer cells may be found in lymph nodes near the stomach. The cancer cells may attach to other tissues and grow to form new tumors that may damage those tissues.

The spread of cancer is called metastasis.

Risk Factor

When you're told that you have stomach cancer, it's natural to wonder what may have caused the disease. But no one knows the exact causes of stomach cancer. Doctors seldom know why one person develops stomach cancer and another doesn't.

Doctors do know that people with certain risk factors are more likely than others to develop stomach cancer. A risk factor is something that may increase the chance of getting a disease.

Studies have found the following risk factors for stomach cancer:

Helicobacter pylori infection: H. pylori is a bacterium that commonly infects the inner lining (the mucosa) of the stomach. Infection with H. pylori can cause stomach inflammation and peptic ulcers. It also increases the risk of stomach cancer, but only a small number of infected people develop stomach cancer. You may want to read the NCI fact sheet Helicobacter pylori and Cancer.

Long-term inflammation of the stomach: People who have conditions associated with long-term stomach inflammation (such as the blood disease pernicious anemia) are at increased risk of stomach cancer. Also, people who have had part of their stomach removed may have long-term stomach inflammation and increased risk of stomach cancer many years after their surgery.

Smoking: Smokers are more likely than nonsmokers to develop stomach cancer. Heavy smokers are most at risk.

Family history: Close relatives (parents, brothers, sisters, or children) of a person with a history of stomach cancer are somewhat more likely to develop the disease themselves. If many close relatives have a history of stomach cancer, the risk is even greater.

Poor diet, lack of physical activity, or obesity:

Studies suggest that people who eat a diet high in foods that are smoked, salted, or pickled have an increased risk for stomach cancer. On the other hand, people who eat a diet high in fresh fruits and vegetables may have a lower risk of this disease.

A lack of physical activity may increase the risk of stomach cancer.

Also, people who are obese may have an increased risk of cancer developing in the upper part of the stomach.

Most people who have known risk factors do not develop stomach cancer. For example, many people have an H. pylori infection but never develop cancer.

On the other hand, people who do develop the disease sometimes have no known risk factors.

Symptoms

Early stomach cancer often does not cause symptoms. As the cancer grows, the most common symptoms are:

Discomfort or pain in the stomach area

Difficulty swallowing

Nausea and vomiting

Weight loss

Feeling full or bloated after a small meal

Vomiting blood or having blood in the stool

Most often, these symptoms are not due to cancer. Other health problems, such as an ulcer or infection, can cause the same symptoms. Anyone who has these symptoms should tell their doctor so that problems can be diagnosed and treated as early as possible.

Diagnosis

If you have symptoms that suggest stomach cancer, your doctor will check to see whether they are due to cancer or to some other cause. Your doctor may refer you to a gastroenterologist, a doctor whose specialty is diagnosing and treating digestive problems.

Your doctor will ask about your personal and family health history. You may have blood or other lab tests. You also may have:

Endoscopy: Your doctor uses a thin, lighted tube (endoscope) to look into your stomach. Your doctor first numbs your throat with an anesthetic spray. You also may receive medicine to help you relax. The tube is passed through your mouth and esophagus to the stomach.

Biopsy: An endoscope has a tool for removing tissue. Your doctor uses the endoscope to remove tissue from the stomach. A pathologist checks the tissue under a microscope for cancer cells. A biopsy is the only sure way to know if cancer cells are present.

Staging

If the biopsy shows that you have stomach cancer, your doctor needs to learn the stage (extent) of the disease to help you choose the best treatment.

Staging is a careful attempt to find out the following:

How deeply the tumor invades the wall of the stomach

Whether the stomach tumor has invaded nearby tissues

Whether the cancer has spread and, if so, to what parts of the body.

When stomach cancer spreads, cancer cells may be found in nearby lymph nodes, the liver, the pancreas, esophagus, intestine, or other organs. Your doctor may order blood tests and other tests to check these areas:

Chest x-ray: An x-ray of your chest can show whether cancer has spread to the lungs.

CT scan: An x-ray machine linked to a computer takes a series of detailed pictures of your organs. You may receive an injection of dye. The dye makes abnormal areas easier to see. Tumors in your liver, pancreas, or elsewhere in the body can show up on a CT scan.

Endoscopic ultrasound: Your doctor passes a thin, lighted tube (endoscope) down your throat. A probe at the end of the tube sends out sound waves that you cannot hear. The waves bounce off tissues in your stomach and other organs. A computer creates a picture from the echoes. The picture can show how deeply the cancer has invaded the wall of the stomach. Your doctor may use a needle to take tissue samples of lymph nodes.

Laparoscopy: A surgeon makes small incisions (cuts) in your abdomen. The surgeon inserts a thin, lighted tube (laparoscope) into the abdomen. The surgeon may remove lymph nodes or take tissue samples for biopsy.

Sometimes staging is not complete until after surgery to remove the tumor and nearby lymph nodes.

When stomach cancer spreads from its original place to another part of the body, the new tumor has the same kind of abnormal cells and the same name as the primary (original) tumor. For example, if stomach cancer spreads to the liver, the cancer cells in the liver are actually stomach cancer cells. The disease is metastatic stomach cancer, not liver cancer. For that reason, it is treated as stomach cancer, not liver cancer. Doctors call the new tumor "distant" or metastatic disease.

These are the stages of stomach cancer:

Stage 0: The tumor is found only in the inner layer of the stomach. Stage 0 is also calledcarcinoma in situ.

Stage I is one of the following:

The tumor has invaded only the submucosa. (The picture shows the layers of the stomach.) Cancer cells may be found in up to 6 lymph nodes.

Or, the tumor has invaded the muscle layer or subserosa. Cancer cells have not spread to lymph nodes or other organs.

Stage II is one of the following:

The tumor has invaded only the submucosa. Cancer cells have spread to 7 to 15 lymph nodes.

Or, the tumor has invaded the muscle layer or subserosa. Cancer cells have spread to 1 to 6 lymph nodes.

Or, the tumor has penetrated the outer layer of the stomach. Cancer cells have not spread to lymph nodes or other organs.

Stage III is one of the following:

The tumor has invaded the muscle layer or subserosa. Cancer cells have spread to 7 to 15 lymph nodes.

Or, the tumor has penetrated the outer layer. Cancer cells have spread to 1 to 15 lymph nodes.

Or, the tumor has invaded nearby organs, such as the liver, colon, or spleen. Cancer cells have not spread to lymph nodes or to distant organs.

Stage IV is one of the following:

Cancer cells have spread to more than 15 lymph nodes.

Or, the tumor has invaded nearby organs and at least 1 lymph node.

Or, cancer cells have spread to distant organs.

Treatment

The choice of treatment depends mainly on the size and location of the tumor, the stage of disease, and your general health.

Treatment for stomach cancer may involve surgery, chemotherapy, or radiation therapy. You'll probably receive more than one type of treatment. For example, chemotherapy may be given before or after surgery. It's often given at the same time as radiation therapy.

Your health care team can describe your treatment choices, the expected results, and the possible side effects. Because cancer therapy often damages healthy cells and tissues, side effects are common. Before treatment starts, ask your health care team about possible side effects, how to prevent or reduce these effects, and how treatment may change your normal activities. You and your health care team can work together to make a treatment plan that meets your needs.

Surgery

The type of surgery for stomach cancer depends mainly on where the cancer is located. The surgeon may remove the whole stomach or only the part that has the cancer.

You and your surgeon can talk about the types of surgery and which may be right for you:

Partial (subtotal) gastrectomy for tumors at the lower part of the stomach: The surgeon removes the lower part of the stomach with the cancer. The surgeon attaches the remaining part of the stomach to the intestine. Nearby lymph nodes and other tissues may also be removed.

Total gastrectomy for tumors at the upper part of the stomach: The surgeon removes the entire stomach, nearby lymph nodes, parts of the esophagus and small intestine, and other tissues near the tumor. Rarely, the spleen also may be removed. The surgeon then connects the esophagus directly to the small intestine.

The time it takes to heal after surgery is different for each person, and you may be in the hospital for a week or longer. You may have pain for the first few days. Medicine can help control your pain. Before surgery, you should discuss the plan for pain relief with your doctor or nurse. After surgery, your doctor can adjust the plan if you need more pain relief.

Many people who have stomach surgery feel tired or weak for a while. Your health care team will watch for signs of bleeding, infection, or other problems that may require treatment.

The surgery can also cause constipation or diarrhea. These symptoms usually can be controlled with diet changes and medicine.

Chemotherapy

Most people with stomach cancer get chemotherapy. Chemotherapy uses drugs to kill cancer cells.

It may be given before or after surgery. After surgery, radiation therapy may be given along with chemotherapy.

The drugs that treat stomach cancer are usually given through a vein (intravenous). You'll probably receive a combination of drugs.

You may receive chemotherapy in an outpatient part of the hospital, at the doctor's office, or at home. Some people need to stay in the hospital during treatment.

Radiation Therapy

Radiation therapy (also called radiotherapy) uses high-energy rays to kill cancer cells. It affects cells only in the part of the body that is treated. Radiation therapy is usually given with chemotherapy to treat stomach cancer.

The radiation comes from a large machine outside the body. You'll go to a hospital or clinic for treatment. Treatments are usually 5 days a week for several weeks.

Side effects depend mainly on the dose and type of radiation. External radiation therapy to the chest and abdomen may cause a sore throat, pain similar to heartburn, or pain in the stomach or the intestine. You may have nausea and diarrhea. Your health care team can give you medicines to prevent or control these problems.

It's common for the skin in the treated area to become red, dry, tender, and itchy.

Overview of Cancer Surgery

Goal of Cancer Surgery

Depending on your cancer type and stage, our goals for treatment are:

Cure : This is the most important goal of cancer surgery. In fact as a cancer patient you are also strongly willing to have cure of cancer for forever. For most of the Liver & Gastro-intestinal cancers perhaps surgery is the first step for cure. Radiation &/or Chemotheray may be advised as an additional tool to achieve this goal.

Control : If your cancer is at a later stage or if previous treatments have been unsuccessful, we aim to control your cancer by removing as much as safely possible. Once you recover from surgery, radiation or chemotherapy is advised as important tool to control your cancer.

Comfort : If you have an advanced stage of cancer or one that hasn't responded to treatments and having symptoms because of tumor i.e pain, jaundice, vomiting, bleeding either in vomitus or in stool, then our multi-specialist team work together to sure you are free of pain and other symptoms.

Role of Surgery for Cancer treatment

Surgery can be done for many reasons for treatment of cancer.

Curative Surgery

Curative surgery is done when cancer is found in only one area, and it’s likely that all of the cancer can be removed. In this case, curative surgery can be the main treatment. It may be used alone or along with chemotherapy or radiation therapy, which can be given before or after the operation.

Diagnostic & Staging Surgery

This type of surgery is used to take out a piece of tissue (biopsy) to find out if cancer is present or what type of cancer it is. The diagnosis of cancer is made by looking at the cells under a microscope. Staging surgery is done to find out how much cancer there is and how far it has spread. The physical exam and the results of lab and imaging tests are used to figure out the clinical stage of the cancer. But the surgical stage (also called the pathologic stage) is usually a more exact measure of how far the cancer has spread. Examples of surgical procedures commonly used to stage cancers, like laparoscopy or laparotomy.

Palliative Surgery

This type of surgery is used to treat problems caused by advanced cancer. It is not done to cure the cancer. For example, cancers of intestine may grow large enough to block off (obstruct) the intestine, or tumor is bleeding and unable to control bleed by medical/endoscopic technique. If this happens, surgery can be used to remove the blockage/control bleeding.

Approach for Surgery:

How surgery is performed? (Special surgery techniques): Open Or Laparoscopic

Open Surgery:

It is the Gold Standard approach for Liver & Gastro-Intestinal cancer. An incision is given on the belly depending upton the underlying location of tumor so that surgeon can directly approach the cancer on cutting the belly. Open Surgery help to remove tumor safely if its adherent to near by blood vessels or organ, that is otherwise difficult in laparoscopic surgery.

Laparoscopic Surgery

A laparoscope is a long, thin, flexible tube that can be put through a small cut (incision) to look inside the body. In recent years, doctors have found that by creating small holes and using special instruments, the laparoscope can be used to perform surgery without making a large cut. This can help reduce blood loss during surgery and pain afterward. It can also shorten hospital stays and allow people to heal faster.

The role of laparoscopic surgery in cancer treatment is not yet clear. Doctors are now studying whether it is safe and effective to use laparoscopic surgeries for cancers of the stomach, colon, rectum & liver. It may prove to be as safe and work as well as standard surgery while cutting less and causing less damage to healthy tissues (being less invasive).

Biopsy of Cancer before Surgery

Biopsy is procedure to confirm the presence of cancer. It’s not essential before surgery. Usually biopsy is performed when 1. Suspicion is cause other than cancer, 2. When surgery cannot be done for cancer due to advanced stage of cancer or 3. Patient is unfit to undergo surgery. In these situation, biopsy guides for further therapy.

If all investigations suggest that cancer can be removed in totality from body, then biopsy can be avoided in to minimize the risk of spillage of cancer cell during biopsy procedure.

There is variety of way to perform biopsies:

Fine Needle Aspiration (FAN) biopsy

Fine needle aspiration (FNA) uses a very thin needle attached to a syringe to pull out small bits of tissue. The needle is guided into the tumor by looking at it using an imaging test, like an ultrasound or CT scan.

The main advantage of FNA is that there is no need to cut through the skin, so there is no surgical incision.

A drawback is that in some cases the needle can’t take out enough tissue for an exact diagnosis. A more invasive type of biopsy (one that involves larger needles or a cut in the skin) may then be needed.

Core Needle biopsy

This type of biopsy uses a larger needle to take out a core of tissue and done under guidance of imaging test like an ultrasound or CT scan. The advantage of core biopsy is that it usually collects enough tissue to find out whether the tumor is cancer.

Excisional or Incisional biopsy

For these biopsies, the surgeon remove the entire tumor (excisional biopsy) or a small part of the tumor (incisional biopsy).

Preparation for Surgery

Our expert team members shall help you to prepare you for surgery. You are strongly advised to stop smoking, stop drinking alcohol, try to improve your diet, lose weight, or actively exercise before surgery.

Pre-operative testing

In most cases, you will need some tests before your surgery. The tests routinely used include:

Blood tests to measure your blood counts, your risk of bleeding or infection, and how well your liver and kidneys are working. Your blood group type is also be checked in case you need blood transfusions during the operation.

USG/CT scans/ MRI to look at the size and location of the tumors and see if the cancer looks like it has spread to nearby tissues.

Anaesthetic Assessment before Surgery:

Our expert team of Anaesthetist will ask you questions pertaining to your health and to assess your fitness for surgery. You are requested to tell them in detail about your current and past medical ailments, allergic reactions you’ve had in the past and current medicines that you are taking like blood thinning medicine. This medicine should be stopped 1 week prior to surgery.

Informed Consent

Informed consent is one of the most important parts of “getting ready for surgery”. It is a process during which you are told about all aspects of the treatment before you give your doctor written permission to do the surgery.

Getting ready for Surgery

Depending on the type of operation you have, there may be things you need to do to be ready for surgery:

Emptying your stomach and bowels (digestive tract) is important. Vomiting while under anaesthesia can be very dangerous because the vomit could get into your lungs and cause an infection. Because of this, you will be asked to not eat or drink anything starting the night before the surgery.

Laxative: You may also be asked to use a laxative or an enema to make sure your bowels are empty.

Shaving of Operative part: You need to have an area of your body shaved to keep hair from getting into the surgical cut (incision). The area will be cleaned before the operation to reduce the risk of infection.

Anaesthesia

Anaesthesia is the use of drugs to make the body unable to feel pain for a period of time. General anaesthesia puts you into a deep sleep for the surgery. It is often started by having you breathe into a face mask or by putting a drug into a vein in your arm. Once you are asleep, an endotracheal or ET tube is put in your throat to make it easy for you to breathe. Your heart rate, breathing rate, and blood pressure (vital signs) will be closely watched during the surgery. A doctor watches you throughout the procedure and until you wake up. They also take out the ET tube when the operation is over. You will be taken to the recovery room to be watched closely while the effects of the drugs wear off. This may take hours. People waking up from general anaesthesia often feel "out of it" for some time. Things may seem hazy or dream-like for a while. Your throat may be sore for a while from the endotracheal (ET) tube.

Recovery from Surgery

Your recovery right after surgery depends on many factors, including your state of health before the operation and how extensive the operation was performed.

Pain

You may feel pain at the site of surgery. We aim to keep you pain free after surgery with the help of latest and most effective technique or analgesic (pain relieving medicine).

Tube/ Drains

You may also have Ryle’s Tube (tube going through nose to stomach) that drain out intestinal fluid. This tube helps to relieve nausea and vomiting after surgery and usually removed 1-2 day after surgery.

You may also have “Tube” (called a Foley catheter) draining urine from your bladder into a bag. This will be taken out soon after surgery, once you are comfortable enough to go to bathroom.

You may have a tube or tubes (called Drains) coming out of the surgical opening in your skin (incision site). Drains allow the excess fluid that collects at the surgery site to leave the body. Drain tube will also be removed once they stop collecting fluid, usually a few days after the operation.

Leg Stocking / Compression boot

As you are remains in bed on day of surgery, circulation of blood in leg become sluggish that may increase possibility of thrombo-embolism. To minimise it, you will be wearing leg stocking/ pneumatic compression boot to improve your leg circulation thus minimising the risk of thrombolism.

Eating and Drinking

You may not feel much like eating or drinking, but this is an important part of the recovery process. Our health care team may start you out with ice chips or clear liquids. The stomach and intestines (digestive tract) is one of the last parts of the body to recover from the drugs used during surgery. You will need to have signs of stomach and bowel activity before you will be allowed to eat. You will likely be on a clear liquid diet until this happens. Once it does, you may get to try solid foods.

Activity

Our health care team will try to have you move around as soon as possible after surgery. They may even have you out of bed and walking the same day. While this may be hard at first, it helps speed your recovery by getting your digestive tract moving. It also helps your circulation and helps prevent blood clots from forming in your legs.

Our team shall also encourage you to do deep breathing exercises. This helps fully inflate your lungs and reduces the risk of pneumonia. You are advised to take deep breaths and cough every hour to help prevent lung infections. You will use an incentive spirometer (a small device used in breathing exercises to prevent complications after major surgery) 10-15 times every hour.

Going home

Once you are eating and walking, all tube/drains placed during surgery are removed, and then you may be ready to go home. Before leaving for home our health care team shall give you detailed guidance regarding diet, activities, medications & further plan of treatment.

Risks and side effects of surgery

There are risks that go with any type of medical procedure and surgery is no longer an exception. Success of surgery depends upon 3 factors: type of disease/surgery, experience of surgeon and overall health of patients. What’s important is whether the expected benefits outweigh the possible risks.

Doctors have been performing surgeries for a very long time. Advances in surgical techniques and our understanding of how to prevent infections have made modern surgery safer and less likely to damage healthy tissues than it has ever been. Still, there’s always a degree of risk involved, no matter how small. Different procedures have different kinds of risks and side effects. Be sure to discuss the details of your case with our health care team, who can give you a better idea about what your actual risks are. During surgery, possible complications during surgery may be caused by the surgery itself, the drugs used (anesthesia), or an underlying disease. Generally speaking, the more complex the surgery is the greater the risk. Complications in major surgical procedures include:

Complications related to Anaesthesia : Reactions to drugs used (anesthesia) or other medicines. Although rare, these can be serious because they can cause dangerously low blood pressures. Your doctors will watch your heart rate, breathing rate, blood pressure, and other signs throughout the procedure to look for this.

Thrombosis (blood clot) in leg & embolism (blood clot) in lung : Blood clots can form in the deep veins of the legs after surgery, especially if a person stays in bed for a long time. Such a clot can become a serious problem if it breaks loose and travels to another part of the body, such as a lung. This is a big reason why you will be encouraged to get out of bed to sit, stand, and walk as soon as possible.

There are specific complications related to type of surgery. You are encouraged with discuss in detail with our health care team before you give your consent for surgery.

Bile leak

Bleed

Complications related to Major Surgery

Infection : Infection at the site of the wound, lung and urinary infection. Infection risk is more if intestine is perforated before surgery, operated for colon and rectum, stent in placed in bile duct to relieve jaundice or intestinal joint is leaking.

Bleeding : The risk of bleeding during or after surgery is more if patient taking blood thinning medicine till day of surgery or having liver dysfunction. Bleeding during surgery that may cause you to need blood transfusions. There is a risk of certain problems with transfusions, some of them serious. Still, some operations involve a certain amount of controlled blood loss. Bleeding can happen either inside the body (internally) or outside the body (externally). It can occur if a blood vessel sealed during surgery opens up or if a wound opens up. Serious bleeding may cause the person to need another operation to find the source of the bleeding and stop it.

Following treatment, you may feel change in your taste. This improves over a time and we encourage having health food habit like fresh vegetables, fruits and high protein diet.

Exercise

Along with healthy food habits, we also encourage for exercise. Exercise improves your health in different ways: It improves your heart and circulation, makes your muscles stronger & makes you feel happier. You should do your regular activities like walking, and rather increase day by day. Weight lifting and strenuous exercise are avoided for initial 2-3 months.

Follow up care

You'll need regular check-ups after treatment for liver cancer. This help to find out any change in your recovery. Sometimes liver cancer comes back after treatment. Our health care team will check for return of cancer. Checkups may include a physical exam, blood tests, ultrasound / CT scan.

If you have any health problems between checkups, you should contact our health care team. Report to our health care team, if you have any redness/ swelling or discharge of any type of fluid from your operative incision site, pain abdomen, vomiting or fever, breathing difficulty etc.